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Chronic open-angle glaucoma (COAG) is an umbrella diagnosis encompassing chronic progressive optic neuropathies with distinctive changes at the optic nerve head and retinal nerve fibre layer that lead to progressive death of retinal ganglion cells, visual field defects and resultant disability.1 It is described as primary: unattributable to pre-existing ocular disease or congenital abnormality. Does the National Institute of Health and Care Excellence (NICE) guidance lead to our patients receiving appropriate treatment?

(a) Who are we treating?

Voltaire, an 18th century philosopher, famously wrote:
“Doctors are men(sic) who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.”

Practising modern 21st century medicine, we are fortunate that critically analysed, robust clinical trials are screened by thorough independent peer review to create highly scientific knowledge of medicines and diseases. This is used to produce algorithms to guide clinical practice for the benefit of the general population. Unfortunately, these guidelines often adopt a one-size-fits-all approach and clinicians find themselves using the same protocols to treat patients who are crudely sorted into broad groups. Consequently the subtle differences of the individual patients in front of us in the clinic are rarely …

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